CCMA Administrative Duties 4

Question 1

A medical assistant receives a subpoena duces tecum requiring the release of a patient's records. The patient has not signed an authorization form. What is the correct course of action?

Accepted Answer

Notify the physician and practice attorney before releasing any records

Answer

A subpoena duces tecum is a legal order to produce records, but the appropriate response is always to notify the supervising physician and the practice's legal counsel first. The attorney can advise whether a court order (not just a subpoena) is required, whether any records are privileged, and how to comply while protecting the practice legally. Releasing records immediately without legal guidance could expose the practice to liability.

Question 2

When using the problem-oriented medical record (POMR) system, in which section of a SOAP note would you document that a patient's blood pressure was 148/92 mmHg on today's visit?

Accepted Answer

Objective

Answer

The Objective section of a SOAP note contains measurable, observable, and quantifiable clinical data gathered by the provider or clinical staff — including vital signs, physical examination findings, and diagnostic test results. A blood pressure reading of 148/92 mmHg is a directly measured value, making it Objective data. The Subjective section contains what the patient reports; Assessment contains the diagnosis or clinical impression; Plan contains treatment decisions.

Question 3

A practice receives an Explanation of Benefits (EOB) showing a claim was denied due to 'CO-4: The procedure code is inconsistent with the modifier.' Which staff action is most appropriate?

Accepted Answer

Review the original claim for modifier-to-procedure code compatibility and correct before resubmitting

Answer

CARC code CO-4 specifically indicates that the modifier used is not compatible with the procedure code billed — it is a billing/coding error, not a medical necessity issue. The correct action is to audit the original claim, identify the incompatible modifier-code pairing, correct it according to payer guidelines, and resubmit. Writing off the balance would be premature and incorrect, and a medical necessity letter would not address a coding incompatibility.

Question 4

Under HIPAA's Minimum Necessary Standard, which situation represents a violation when disclosing PHI to another covered entity?

Accepted Answer

Transmitting the complete medical record, including unrelated psychiatric history, for a routine orthopedic consultation

Answer

The HIPAA Minimum Necessary Standard requires that only the PHI reasonably necessary to accomplish the intended purpose be used or disclosed. Sending a complete medical record — including unrelated psychiatric history — for an orthopedic consultation exceeds what is minimally necessary. Psychiatric records carry heightened sensitivity and should only be disclosed when directly relevant to the treatment being sought. The other options represent appropriate, limited disclosures tied to the specific need.

Question 5

A physician practice is transitioning from ICD-10-CM to the next coding cycle. The practice manager instructs the MA to use an ICD-10-CM code that was valid last fiscal year but has since been deactivated without a direct replacement. What should the MA do?

Accepted Answer

Query the physician for clarification and consult the current ICD-10-CM tabular list to find the most specific applicable code

Answer

When a code is deactivated without a direct replacement, the correct process is to query the treating physician to clarify the clinical diagnosis and then consult the current ICD-10-CM tabular list (not the alphabetical index alone) to identify the most specific valid code for the condition. Using a deleted code will result in claim rejection, defaulting to an unspecified code is inappropriate when a more specific code exists, and submitting without a diagnosis code is not compliant with payer requirements.

CCMA - Certified Clinical Medical Assistant Practice Test

CCMA - Certified Clinical Medical Assistant Practice Test

CCMA Administrative Duties 4